Provider Demographics
NPI:1386101509
Name:DE LA NOVAL LORENZO, PAVEL EDUARDO (APRN)
Entity type:Individual
Prefix:
First Name:PAVEL
Middle Name:EDUARDO
Last Name:DE LA NOVAL LORENZO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 S ROYAL POINCIANA BLVD APT 21
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-7325
Mailing Address - Country:US
Mailing Address - Phone:786-556-2395
Mailing Address - Fax:
Practice Address - Street 1:711 S ROYAL POINCIANA BLVD APT 21
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-7325
Practice Address - Country:US
Practice Address - Phone:786-556-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001599363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty